Canadians now know how cruelly the Correctional Service of Canada failed Ashley Smith, and what needs to be done to help others like her.

In a stinging rebuke to the correctional service, the jury in the Ashley Smith inquest returned a verdict of homicide, meaning that someone else contributed to her death.

Published on Thu Dec 19 2013

Ashley Smith’s troubled young life was a cry of pain and a call for help that fell on deaf ears. As she was bounced around Canada’s prison system, a harrowing video shows her aboard a small plane, hooded, shackled, “pig-chained” and having her wrists duct-taped after guards decided she needed to be fully restrained.

When a Royal Canadian Mounted Police pilot warns her to settle down, Smith asks “How can it get worse?” The pilot’s reply: “I’ll duct-tape your face.” That’s how much worse.

Six months later, on Oct. 19, 2007, Smith choked herself to death with a strip of cloth while guards at the Grand Valley Institution for Women in Kitchener looked on and did nothing. She was 19.

While it has taken years for the full truth to come out, Canadians now know just how cruelly the Correctional Service of Canada failed her, thanks to the patient work of Toronto coroner Dr. John Carlisle and the inquest into her death. In a stinging and much-deserved rebuke to the correctional service, the jury returned a verdict of homicide, meaning that someone else contributed to her death, the Star’s Donovan Vincent and Diana Zlomislic report. In all, the jury made 104 recommendations to spare others from a similar fate. They need speedy implementation.

As Dr. Carlisle rightly noted, “Canadians look forward to action.”

Incidents of self-harm in prisons rose past 900 in the past year, tripling in the years since Smith died, reports Howard Sapers, the federal corrections ombudsman. Of the 264 inmates who hurt themselves by biting, cutting, head-banging or self-suffocating, a disproportionate number were aboriginal and female. A handful of 17 chronic self-injurers stood out, including nine women. Guards resort to physical restraint, segregation, shackles, pepper spray and other tools to control and prevent self-harm. But all too often this just makes inmates more combative and extreme.

Sadly, Smith fell into this category. She was a deeply disturbed teen from Moncton, N.B., who was diagnosed with hard-to-treat borderline personality disorder. She was jailed at 15 as a youth for throwing crabapples at a postal worker. But she didn’t belong in jail. The system couldn’t cope with her. She was a chronic self-injurer who put herself at risk by constantly tying ligatures around her neck, and who fought with guards who came to her aid. Her initial four-month youth sentence grew to four years for assault and vandalism while in custody.

In the last year of her life she was shuffled 17 times among institutions in four provinces. She spent up to 23 hours a day in segregation, was forcibly restrained and injected with drugs against her will. She should have been in psychiatric care.

She strangled herself after she was given extra time for assaulting a guard, and knew she couldn’t go home for Christmas. Although she was on suicide watch, guards who had rushed in to remove her ligatures in the past hesitated because prison managers were concerned about using too much force, too often. The guards were instructed not to intervene unless she was showing signs of medical distress or imminent risk by not moving or not breathing. Instead they were to “assess and reassess” first.

The Smith family is now calling for a criminal probe of Grand Valley’s acting warden in 2007 and her deputy.

In the wake of Smith’s death Correctional Service of Canada has made some painfully obvious changes, including instructing guards to remove ligatures immediately from self-harming inmates. But much remains to do and Prime Minister Stephen Harper needs to ensure that the prison service has the necessary funds.

Chief among the jury’s recommendations:

Smith’s experience should be taught as a “case study” in how the system failed. Staff should get better training in dealing with women who have mental health issues or who hurt themselves.

Frontline staff should be instructed to make “preservation of life” the priority and not be required to seek permission to intervene.

Women should be assessed within 72 hours of arriving in prison, and a treatment strategy developed.

There should be more than one federal “treatment facility” where inmates like Smith can get medical care, instead of being warehoused in security-focused, prison-like conditions. Centres should be set up in Ontario and regionally. Deals should also be made with the provinces to provide care. There should be a patient advocate. Women shouldn’t be held in segregation or isolation for more than 15 days. And they should be kept in the region closest to their family.

It is brutally clear, too, that Canada’s justice system urgently needs an infusion of compassion. Ashley’s tragedy shames us all.

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